Healthcare Provider Details

I. General information

NPI: 1083873897
Provider Name (Legal Business Name): PRIMARY CARE PHYSICIANS OF SANFORD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 W 1ST ST
SANFORD FL
32771-1205
US

IV. Provider business mailing address

309 W 1ST ST
SANFORD FL
32771-1205
US

V. Phone/Fax

Practice location:
  • Phone: 407-324-5035
  • Fax: 407-321-5266
Mailing address:
  • Phone: 407-324-5035
  • Fax: 407-321-5266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS6401
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS6404
License Number StateFL

VIII. Authorized Official

Name: MR. VINCENT JOSEPH MAMONE
Title or Position: PRESIDENT
Credential: D.O
Phone: 407-324-5035